Since the 1990’s, scientific studies have repeatedly shown that OCD in children can be successfully and safely treated with cognitive behavioral therapy (CBT) —specifically, a type of CBT called exposure and response prevention (ERP). CBT has a 65–80% success rate with children and adolescents, similar to the success rate with adults.
Why is it effective?
ERP is based on the premise that OCD is maintained and exacerbated because compulsive behaviors (also called rituals) and avoidance behaviors provide relief from anxiety. For instance, when 8-year-old Casey touches crayons, he worries about poison. He quickly washes his hands and then feels much better. Casey soon learns that washing his hands lessens his anxiety. However, Casey’s OCD is actually worsened by washing his hands because it prevents him from learning that his obsessions are improbable and that his anxiety will subside naturally.
ERP teaches youth with OCD to face their fears while refraining from compulsions. It helps them realize that their obsessive fears do not come true and that the anxiety they experience subsides as a result of a process referred to as habituation, or a gradual lessening of their anxiety response. ERP for Casey would involve having him face his fear that the crayons are “poisonous” by touching them and not washing his hands afterwards.
Obstacles to treatment
ERP is widely considered the treatment of choice for children with OCD. However, it is estimated that the majority of children and adolescents with OCD do not receive ERP due to the limited number of clinicians with expertise in ERP for OCD in kids and teens. Therapists who treat children and adolescents with OCD must understand the unique needs and cognitive capabilities of children. Often, the therapist may be challenged by a child’s reluctance to engage in ERP because he or she thinks that facing fears without performing rituals will simply be too scary and impossible. Children who are not properly prepared for how ERP works and what it entails are more likely to become ambivalent or afraid, withdraw from exposures, and refuse to practice.
The therapist must find a way to help the child get past the discomfort of giving up rituals that seem to protect him or her against overwhelming fears. To do that, the ERP therapist must use a child-friendly approach that cultivates treatment readiness before rushing into ERP. An important part of treatment readiness is helping children and families understand how compulsive behaviors and avoidance strengthen OCD, that OCD is overcome by confronting fears (exposure), learning that they are false alarms, and experiencing habituation (getting used to the anxiety).
Metaphors, analogies and games can be useful in helping children understand these concepts. When youngsters understand how exposure and habituation work, they are more willing to tolerate the initial anxiety experienced during ERP because they know it will increase and then subside. Active parent involvement in the child’s treatment is also important. ERP is a collaborative treatment, with the therapist, parents, and child working together as a team to overcome OCD.
The need for a well-rounded plan
An ERP treatment plan is designed to improve the overall wellbeing of the child, not just his or her obsessions and compulsions. The child may need treatment to improve self-esteem and help rebuild social skills, family relationships, and academic functioning. OCD symptoms should generally be treated first unless other issues interfere with treatment. For example, severe depression or family conflict may need to be treated before a child can engage in ERP.
If you are a licensed clinician and wish to receive training in ERP for pediatric OCD, click here to learn about the IOCDF Training Institute and the Pediatric BTTI.